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Obamacare and Prisoner Substance Abuse Treatment

An astonishing two-thirds of the 730,000 men and women released from America’s lockups each year have either substance abuse problems, mental health problems, or both. Very often, those problems were largely responsible for getting them locked up in the first place. Most addicted and mentally ill prisoners receive little or no effective treatment while they’re incarcerated or after they’re turned loose, so it’s little surprise that they soon wind up back in jail. But for some, that revolving door may stop spinning this year, thanks to a little-noticed side-effect of President Obama’s Affordable Care Act. Obamacare, it turns out, might be a crime-fighting tool.

Numerous studies support the common-sense notion that treating offenders’ drug addictions and mental illnesses helps keep at least some of them from going back to jail. “It’s not the drug itself, it’s the stealing and robbing they do to get the drug,” says Abbie Zimmerman, a therapist at Transitions Clinic, a program based in San Francisco’s hard-bitten Hunter’s Point area that treats former prisoners “If I can keep them sober, I can keep them out of jail.”

But no one has been willing to pay for such treatment for hundreds of thousands of ex-cons. And they certainly can’t afford it themselves: According to a recent report by the Council of State Governments, the vast majority of released prisoners re-enter society with little money and no health insurance. But now many of those former prisoners are eligible for insurance, courtesy of the federal government.

Among many other reforms, the ACA is drastically expanding Medicaid, the federal insurance scheme for the poor. Previously, able-bodied childless adults were generally not covered by Medicaid, regardless of how impoverished they might have been. But starting this year, any American citizen under age 65 with a family income at or below 138 percent of the federal poverty line—about $25,000 for a family of three—is eligible for Medicaid (at least in the two dozen states that have so far agreed to participate in this aspect of Obamacare). Meanwhile, citizens and legal immigrants earning between 138 percent and 400 percent of the poverty line are now entitled to subsidies to help pay for private insurance. Taken together, those two provisions mean that tens, perhaps hundreds, of thousands of the inmates released every year are now eligible for health insurance, including coverage for mental health and substance abuse services.

Providing treatment to those former prisoners could yield enormous benefits for all of us. The average cost to incarcerate someone for a year is roughly $25,000. That means if only one percent of each year’s released inmates stay out of trouble, taxpayers will save nearly $200 million annually—and the pool of troubled ex-cons looking to steal your car stereo will be that much smaller. “Success in implementing the Affordable Care Act has the potential to decrease crime, recidivism, and criminal justice costs, while simultaneously improving the health and safety of communities,” sums up a recent report by the federal Department of Justice.

It all looks great on paper. But there are significant obstacles to making this work in the real world. One is the simple fact that many former prisoners aren’t even aware of their new entitlements. “I don’t really know what Obamacare is,” says Ernest Kirkwood, a Transitions client who spent 29 years in prison, when I tell him I’d like to talk to him about the new health care regime. “I never read the newspaper.”

Making services available is one thing. Getting people whose judgment isn’t that great in the first place to actually use them is another. Plenty of drug users and mentally ill people don’t want to admit they have a problem. The stigma that persists around mental illness keeps some should-be patients away. Richard Rawson, a professor of psychiatry specializing in substance abuse at the University of California, Los Angeles, points out that an earlier experiment that provided residential treatment to just-released drug offenders didn’t work as well as hoped. “People said, ‘I just got out, I don’t want to be in rehab for another year,’” he says. And of course, many former inmates need more than just treatment to keep them straight—basics like decent housing and a job are also critical.

“Even with all that, this is a watershed opportunity,” says Rawson. “It should put a significant dent in recidivism, no question.” Accordingly, government agencies, public health officials, and prisoner support organizations across the country are working to connect inmates with Obamacare. “We’re trying to enable people to enroll at many points in the criminal justice system, so they can walk into services the day they leave prison,” says Maureen McConnell, a spokesperson forTreatment Alternatives for Safe Communities, a Chicago non-profit. Her group, working with the Cook County Sheriff’s Department, is sending outreach workers into jails to get thousands of inmates started on the paperwork before they’re released. Illinois Governor Pat Quinn has formed a working group targeting the issue. Massachusetts has implemented an electronic Medicaid application system for inmates leaving incarceration. Similar efforts are underway in California, Maryland, and other states.

Even the most determined outreach campaign won’t succeed in enrolling every single former prisoner, and not all of those who enroll will bother getting treatment. But at least some will get the help they need when they are sent back out on the streets.